Conservative and surgical treatment of the chronic Charcot foot and ankle

Compressive Strength of Midfoot Fusion Nail vs Midfoot Fusion Bolt and Role of Subtalar Fusion in Midfoot Charcot Fixation Model

BACKGROUND

Operative management of midfoot Charcot arthropathy often involves an extended midfoot arthrodesis with intramedullary bolts for fixation, a method called "beaming." Recently intramedullary nails have been introduced for the same indication, presumably providing stronger fixation. This study compares midfoot fusion nails to bolts with regard to stiffness and compressive ability. Additionally, we assessed how the addition of a subtalar fusion affects the construct.

METHODS

Medial column fusions were performed on 10 matched cadaver foot specimens with either a midfoot fusion nail or bolt. Specimens underwent cyclical compression loading, and displacement was measured. Separately, compressive forces produced were compared between the 2 fixation constructs using a synthetic bone block model. Lastly, another 10 matched specimens with midfoot fusion nails were evaluated with or without subtalar fusions.

RESULTS

No differences in stiffness were found in comparing matched specimens between nail vs bolt or comparing nail only without subtalar fusion (STF) vs nail with STF. The compressive force produced by the nail specimens was significantly and substantially greater than the bolted specimens (751.7 vs 139.0 N, P = .01). The accumulated height drop at the midfoot after cycling was 0.5 mm more in the nail group than in the bolt group (1.72 vs 1.22 mm, P = .008). The nail with STF group had greater initial height drop at the midfoot than the nail-only group (0.68 vs 0.34 mm, P = .035) with similar initial height drop at the ankle. However, there were no differences in strength among the matched pairs of midfoot nail-only vs midfoot nail with STF as measured by displacement after fatigue or maximum force at load to failure.

CONCLUSION

The overall cadaveric comparisons between matched pairs of nails vs bolts, and nail-only vs nail with STF, did not provide noteworthy differences between the groups with regard to strength or stiffness. However, the compressive force of the midfoot fusion nail was far superior to the bolt in a synthetic bone model. These data provide valuable insight comparing implants used in Charcot midfoot arthrodesis.

Brazilian Society of Angiology and Vascular Surgery 2023 guidelines on the diabetic foot

The diabetic foot interacts with anatomical, vascular, and neurological factors that challenge clinical practice. This study aimed to compile the primary scientific evidence based on a review of the main guidelines, in addition to articles published on the Embase, Lilacs, and PubMed platforms. The European Society of Cardiology system was used to develop recommendation classes and levels of evidence. The themes were divided into six chapters (Chapter 1 - Prevention of foot ulcers in people with diabetes; Chapter 2 - Pressure relief from foot ulcers in people with diabetes; Chapter 3 -Classifications of diabetic foot ulcers; Chapter 4 - Foot and peripheral artery disease; Chapter 5 - Infection and the diabetic foot; Chapter 6 - Charcot's neuroarthropathy). This version of the Diabetic Foot Guidelines presents essential recommendations for the prevention, diagnosis, treatment, and follow-up of patients with diabetic foot, offering an objective guide for medical practice.

An overview of complications associated with type 1 and type 2 diabetes

Elevated blood glucose levels (hyperglycaemia) and insulin resistance over time are determinants of the onset and progression of a range of complications associated with diabetes mellitus, including cardiovascular disease, neuropathy (nerve damage), diabetic kidney disease and eye conditions. Maintaining optimal glycaemic control may reduce the risk of developing such complications and has been shown to reduce the severity of some renal and eye conditions. However, achieving optimal glycaemic control can be challenging because of various physical and psychological factors that can cause fluctuations in blood glucose levels. This article provides an overview of some of the complications associated with type 1 and type 2 diabetes.

Fibular strut graft for primary ankle arthrodesis in diabetic charcot neuroarthropathy patients

INTRODUCTION

Arthrodesis is an expensive procedure that is less applicable in developing countries. In this case report we reported a case of diabetic charcot neuroartropathy (CN) with primary ankle arthrodesis technique with a fibular strut graft which is considered cheaper and has a higher union rate.

CASE DESCRIPTION

A 47 years old female with complaints of pain in her right ankle after falling down the stairs with foot inverted one month before admission. The patient has uncontrolled diabetes mellitus with HbA1C 7.6 % and random blood sugar check >200 mg/dl. The patient's pain score using the visual analog score (VAS) showed a value of 8. While plain film X-ray revealed bony fragmentation in the Ankle joint. Arthrodesis surgery using fibular strut graft was performed. The postoperative X-ray examination revealed two plates attached to the anterior and medial distal tibia. A total of nine wires were attached to the patient. The patient used Ankle Foot Orthosis (AFO) and was able to walk normally 3-weeks post-surgery without pain and ulcer formation.

DISCUSSION

Fibular strut graft has good cost-effectiveness, that is more suitable for use in developing countries. It also requires a simple implant that is easily applied by all orthopedists. Fibular strut graft has the advantage of having osteogenic, osteoinductive, and osteoconductive properties that can potentially improve union.

CONCLUSION

The fibular strut graft technique can be an alternative in obtaining durable ankle fusion and functional salvaged limb with low complications.

Diabetic Foot Osteomyelitis: Is it all the Same?

Diabetic foot osteomyelitis (OM) requires a longer duration of therapy, a greater need for surgery and implies a higher rate of recidivism, a higher amputation risk, and lower treatment success. But do all bone infections behave the same way, require the same treatment, or imply the same prognosis? Actually, in clinical practice we can verify there are different clinical presentations of OM. The first one is that associated with the infected diabetic foot attack. It requires urgent surgery and debridement since "time is tissue." Clinical features and radiographs are enough for the diagnosis, and treatment should not be delayed. The second one is related to a sausage toe. It affects phalanges and it can be treated with a 6- or 8-week antibiotic course with a high rate of success. Clinical features and radiographs are sufficient for the diagnosis in this case. The third presentation is OM superimposed to Charcot's neuroarthropathy, which mainly comprises midfoot or hindfoot. It starts with a plantar ulcer in a foot that has developed a deformity. The treatment is based on an accurate diagnosis that often includes magnetic resonance, and requires a complex surgery to preserve the midfoot and to avoid recurrent ulcers or foot instability. The final presentation is that of an OM without large soft tissue compromise secondary to a chronic ulcer or a previous unsuccessful surgery secondary to minor amputation or debridement. There is often a small ulcer with a positive probe to bone test over a bony prominence. Diagnosis is made by clinical features, radiographs, and laboratory tests. Treatment includes antibiotic therapy guided by surgical or transcutaneous biopsy, but this presentation often requires surgery. Different presentations of OM mentioned above need to be recognized because the diagnosis, type of culture, antibiotic treatment, surgical treatment, and prognosis are different upon the presentation.

Diagnosis and Treatment of Neuropathic Ankle Fractures

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Standard 3-view ankle radiographs are the first-line imaging modality for suspected neuropathic ankle fractures. Computed tomography is helpful to evaluate for concomitant osseous changes and soft-tissue infection.

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Nonoperative management may be considered for low-demand, elderly, or comorbid patients for whom surgery and anesthesia are contraindicated. However, the presence of comorbidities alone should not necessarily preclude operative intervention. Given the overall poor results of nonoperative treatment in the neuropathic ankle fracture population, operative intervention may in fact be less risky to the patient.

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The authors have 2 preferred treatment techniques. For cases in which the vascular supply and bone stock are adequate, open reduction and internal fixation (ORIF) with locking fixation for the fibula, a medial buttress/hook plate with lag screws for the medial malleolus, multiple syndesmotic screws for additional fixation even in the absence of a syndesmotic injury, and temporary transfixation Steinmann pins from the calcaneus into the tibia are used. For cases in which there is a concern for wound healing or previously failed ORIF, minimally invasive surgical tibiotalocalcaneal arthrodesis with a retrograde locked intramedullary nail is used.

Musculoskeletal complications in patients with diabetes mellitus

Musculoskeletal conditions are common in patients with diabetes. Several musculoskeletal disorders are viewed as chronic complications of diabetes because epidemiological studies have revealed high correlations between such complications and diabetes, but the pathophysiological links with diabetes remains unclear. Genetic predispositions, shared risk factors, microvascular impairments, progressive accumulation of advanced glycation end-products, and diabetic neuropathy may underlie the development of musculoskeletal disorders. Musculoskeletal complications of diabetics have received less attention than life-threatening microvascular or macrovascular complications. Here, we review several diabetic musculoskeletal complications with a focus on the clinical importance of early recognition and management, which would improve quality of life and physical function.

Conservative Management of Charcot Neuroarthropathy

Charcot can be a difficult clinical entity to diagnose in the acute phase, and clinicians should have a high clinical suspicion in neuropathic patients who present with erythema, edema, and warmth of the foot or ankle. Immobilization and nonweight-bearing should be immediately initiated when the diagnosis of Charcot has been made and patients should remain nonweight-bearing until the affected bones/joints have coalesced. Educating patients and managing expectations is crucial to improve compliance with the conservative treatment of Charcot and avoid the long-term sequelae including severe deformity, ulceration and infection, and amputation.

Comparative Analysis of Secondary Outcomes in Treatment of Charcot Neuropathy: A Systematic Review

BACKGROUND

Charcot neuroarthropathy (CN) is commonly associated with diabetic neuropathy and can predispose patients to amputations. Management remains a challenge, with no definitive treatment. This study examines major postoperative complications associated with open reduction with internal (intramedullary) nails, fixation, external fixation, or combined internal and external fixation for correction of the deformity.

METHODS

We reviewed available literature using PubMed, OvidSP, Scopus, and Cochrane and searched bibliographies of the included studies to identify additional pertinent references. After review and agreement among 4 raters, a total of 15 studies were included in this analysis.

RESULTS

Hardware removal rates were 0.133 for intramedullary nails, 0.007 for external fixators, and 0.050 for combined fixation. Rates of hardware complication were 0.182 for intramedullary nails and 0.007 for external fixators. Wound dehiscence occurred at rates of 0.059 for intramedullary nails and 0.216 for combined fixation. The rate of deep infections was 0.031 for intramedullary nails, 0.032 for external fixators, and 0.113 for combined fixation. The rate of irrigation and debridement was 0.007 for external fixators.

CONCLUSION

Rates of hardware removal (13.3%) and complications (18.2%) were high with intramedullary nails. Dehiscence (21.6%) and deep infection (11.3%) were high in combined fixation. Other complications occurred relatively rarely.

LEVEL OF EVIDENCE

Level III.

Inappropriate antibiotic administration in the setting of Charcot arthropathy: A case series and literature review

AIMS

Differentiating Charcot neuropathic osteoarthropathy (CN) from infection is challenging. The diagnosis of CN is often missed or delayed, resulting in inappropriate and delayed treatment. We hypothesized that the misdiagnosis of CN results in inappropriate antibiotic prescriptions and explore the sequelae of unnecessary antibiotic use.

METHODS

A retrospective review of patient electronic medical records from January 2010 to December 2017 was conducted for those diagnosed with CN after being referred to an orthopaedic foot and ankle specialist.

RESULTS

Our review showed 58 of 103 (56%) patients received antibiotics on the date, or within the next 7 days, of referral to foot and ankle orthopaedic specialist. The antibiotic of choice given on referral were as follows: Sulfamethoxazole/Trimethoprim 18 of 58 (31%), doxycycline 13 of 58 (22%), clindamycin 13 of 58 (22%), cephalexin 9 of 58 (16%), minocycline 5 of 58 (9%).

CONCLUSION

Missed diagnoses for CN are common and result in complications stemming from inappropriate treatment, delays in appropriate therapy, and may accelerate antibiotic resistance. Misdiagnosis of CN contributes to the inappropriate use of prescription antibiotics.

Different approach to charcot neuroarthropathy: A case report

Introduction and importance

Charcot neuroarthropathy (CN) is a degenerative, progressive disease affecting the ankle and foot and it is usually a disabling factor in diabetic patients. Surgical management of CN aims to obtain a painless stable plantigrade foot which can be achieved through fusion. Achieving joint arthrodesis in CN usually carries a high failure rate.

Cases presentation

We presented two patients with late-stage CN foot deformity. The first case is a 52-year-old female with CN on her left ankle and presented without any infection or prior correction. The second case reported a 47-year-old man with complaints of deformity on his right ankle, he had undergone surgical treatment with an external fixator before, and now presented with infection in the surgical site.

Clinical discussion

Ankle arthrodesis has been considered by many as the treatment of choice for severe and late-stage CN foot. This treatment aims to give a rigid enough fixation which will maintain the stability of the ankle joint and prevents further destruction of surrounding tissue. Multiple modalities of treatment are available and must be chosen accordingly to each clinical case. Minimal implants and the use of multiple bone grafts could be considered as a plan of treatment. Both patients have promising and positive results from the two procedures.

Conclusion

Treatment of CN Foot with internal plate fixation combined with fibular strut graft seemed to give promising results, both radiographically and functionally. Furthermore, a slight modification of treatment with a minimal implant or iliac graft may be considered.

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We present case reports consist of 2 patients with CN and diabetes mellitus condition.

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The management for this varied condition has not described in many published literatures.

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We performed minimal implant and multiple bone grafts technique surgery in different kind of patient's condition, both in non-infected and infected patient.

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The follow up of clinical and radiograph imaging shows satisfiying outcome, and both patients now progresses to a partially weight bearing and continue to give promising results.

Long-term follow-up of conservative treatment of Charcot feet

BACKGROUND

Charcot arthropathy (CN) can ultimately lead to limb loss despite appropriate treatment. Initial conservative treatment is the accepted treatment in case of a plantigrade foot. The aim of this retrospective study was to investigate the mid- to long-term clinical course of CN initially being treated conservatively, and to identify risk factors for reactivation and contralateral development of CN as well as common complications in CN.

METHODS

A total of 184 Charcot feet in 159 patients (median age 60.0 (interquartile range (IQR) 15.5) years, 49 (30.1%) women) were retrospectively analyzed by patient chart review. Rates of limb salvage, reactivation, contralateral development and common complications were recorded. Statistical analysis was performed to identify possible risk factors for limb loss, CN reactivation, contralateral CN development, and ulcer development.

RESULTS

Major amputation-free survival could be achieved in 92.9% feet after a median follow-up of 5.2 (IQR 4.25, range 2.2-11.25) years. CN recurrence occurred in 13.6%. 32.1% had bilateral CN involvement. Ulcers were present in 72.3%. 88.1% patients were ambulating in orthopaedic footwear without any further aids. Presence of Diabetes mellitus was associated with reactivation of CN, major amputation and ulcer recurrence. Smoking was associated with ulcer development and necessity of amputations.

CONCLUSIONS

With consistent conservative treatment of CN with orthopaedic footwear or orthoses, limb preservation can be achieved in 92.9% after a median follow-up of 5.2 years. Patients with diabetic CN are at an increased risk of developing complications and CN reactivation. To prevent ulcers and amputations, every effort should be made to make patients stop smoking.

LEVEL OF EVIDENCE

III, long-term retrospective cohort study.

A Pilot Survey: Knowledge of Charcot Neuroarthropathy Among Family and Internal Medicine Practitioners

Charcot neuroarthropathy secondary to diabetes mellitus is a serious complication, requiring specialist management. As a relatively rare pathology bearing similarity to other, more common diseases, it may be misdiagnosed at initial presentation, potentially leading to delays in appropriate management. We conducted a 2-part online survey of primary care physicians within an academic medical institution to assess knowledge of presentation, complications, diagnosis, and treatment of Charcot neuropathy. The first section was designed to assess physician knowledge of Charcot foot, while the second section was completed only by physicians who were familiar with the condition and was designed to gauge their level of knowledge. Most clinicians were familiar with Charcot, encountering it at least annually. They identified common signs of Charcot (eg, swelling, pain) and complications due to its mismanagement (eg, ulcer, amputation). However, there was some disagreement on how to diagnose the pathology, with some relying on film, others referring to specialists, and some saying they were unsure. There was uncertainty on when to choose surgical options; fewer than half referred to specialists for help with this decision, and a quarter were unsure how to make the decision. While, in general, clinicians were aware of Charcot and its characteristics, there was confusion regarding how to diagnose or appropriate nonsurgical treatment.

Diagnosis and treatment of Charcot arthropathy in diabetic patients

Background: Charcot joint or neurogenic arthropathy in diabetes is a late complication invading the foot and ankle that results in dislocation, instability, and deformity of the affected area. Sensory neuropathy leads to numbness and malalignment of the foot and ankle or inadequate post-traumatic response, which results in progressive fractures, multiple joint dislocations, ulcerations, osteomyelitis, and amputation. Because of such serious consequences, understanding of pathophysiology is important in determining treatment strategies. Early diagnosis and appropriate treatment can prevent this destructive process.Current Concepts: The number of adults diabetic patients continuously increases. Health care and life expectancy will continue to improve with the development of medicine. As a result, the incidence of diabetes-related complications will increase. Diabetic Charcot joint will have a serious negative impact on the quality of life and financial burden on the diabetic patients. The goal of treatment for Charcot joint is not to build a normal foot, but to make a stable plantigrade foot that can be worn shoes. Therefore, it would be most important to understand the progress and characteristics of the disease and to develop an appropriate plan in order to select the appropriate treatment method.Discussion and Conclusion: Understanding Charcot joint and familiarization with its appropriate treatment should reduce the number of the cases of diabetic Charcot joint patients with disabilities or amputations.

Computer-Assisted Gradual Correction of Charcot Foot Deformities: An In-Depth Evaluation of Stage One of a Planned Two-Stage Approach to Charcot Reconstruction

The surgical treatment of Charcot foot is a widely debated topic, with issues ranging from when to operate to how to properly correct a deformity. Historically, correction of a severe deformity was attempted in 1 acute surgical procedure that frequently required open reduction and internal fixation through large incisions. This 1-time procedure would often result in complications including under- or overcorrection of the deformity, neurovascular injury, or incision dehiscence leading to possible soft-tissue infection or osteomyelitis. This retrospective case series aims to evaluate stage 1 of a planned 2-stage approach to Charcot deformity correction, consisting of gradual modification with the use of computer-assisted external fixation. The purpose of using gradual correction was to safely and accurately correct the Meary and calcaneal inclination angles, which were measured using preoperative and postoperative digital radiographs. The procedure was performed on 18 Charcot foot deformities in 18 patients. Each of the feet had a notably significant rocker bottom deformity and most contained an ulceration. Complete ulcer healing was noted in 100% (13/13) of feet with an ulcer, and a statistically significant corrected Meary's (p < .05) and calcaneal inclination angle (p < .05) to within a normal range was achieved in all deformity corrections with few postoperative problems and complications noted. Average patient follow-up was 39.6 months with a minimum of at least 12 months necessary for inclusion in the study. Therefore, gradual Charcot deformity correction through the use of computer-assisted hexapod external fixation, demonstrates safe, accurate, and reproducible characteristics that adequately prepares the lower extremity for stage 2, the implantation of rigid internal fixation.

Incidence and Predictive Factors for Amputations Derived From Charcot's Neuroarthropathy in Persons With Diabetes

Charcot's neuroarthropathy (CN) is the progressive destruction of the bones and joints of the feet, as a consequence of severe peripheral neuropathy, which predisposes patients to amputations. The purpose of this study was to measure the cumulative incidence of amputations resulting from CN and risk factors among amputated people with diabetes mellitus (DM). This was an epidemiological, observational, and retrospective study of 114 patients with DM who had an amputation involving the lower limbs. Data were collected from 2 specialized outpatient clinics between 2015 and 2019, including socio-demographic and clinical variables (cause of amputation: CN, peripheral arterial disease [PAD], infected ulcers, fracture, osteomyelitis, and others; body mass index [BMI]; 1 or 2 DM, time since DM diagnosis, insulin treatment, glycated hemoglobin; creatinine; smoking and drinking; systemic arterial hypertension, diabetic retinopathy, diabetic kidney disease, diabetic peripheral neuropathy, acute myocardial infarction, PAD, and stroke; characteristics of amputation [level and laterality], in addition to the specific variables related to CN [time of amputation in relation to the diagnosis of CN, diagnosis of CN in the acute phase, and treatment implemented in the acute phase]). We compared socio-demographic and clinical characteristics, including types of amputation, between patients with and without CN. Statistical analyses were performed using the 2 sample t-test or Wilcoxon-Mann-Whitney test, for quantitative variables, and the Pearson's χ² test or Fisher's exact test for categorical variables. The investigation of the possible association of predictive factors for a CN amputation was carried out through logistic regression. The amputation caused by CN was present in 27 patients with a cumulative incidence of 23.7% in 5 years. There was a statistically significant association between BMI and the occurrence of CN (odds ratio: 1.083; 95% confidence interval: 1.001-1.173; P = .048); higher values of BMI were associated with a higher occurrence of amputations secondary from CN.

Outcomes of Tendo-Achilles lengthening and weight-bearing total contact cast for management of early midfoot charcot neuroarthropathy

AIM OF STUDY

To report outcomes of tendo-Achilles lengthening (TAL) followed by weight-bearing total contact cast (TCC) in the out-patient setting for patients presented with midfoot Charcot neuroarthropathy (CN) and, develop a new classification system for midfoot CN based on this experience.

PATIENT AND METHODS

Published evidence suggests that tight Achilles-gastrocnemius-soleus complex is the deforming force in the initiation and progression of midfoot CN and TAL has shown to improve the range of ankle dorsiflexion and reduction of midfoot plantar pressures. We utilised this technique in the out-patient setting followed by weight-bearing TCC for all new patients who presented with a diagnosis of midfoot CN from February 2018.We report their outcomes after a 12 months follow-up and propose a new classification system based on the clinical and radiographic parameters.

RESULTS

TAL followed by weight-bearing TCC was performed in 33 feet. In 30 feet, the disease progression either stopped or receded to a lower stage on the new classification system. The procedure was well tolerated by patients in an out-patient setting and there were no reported complications such as wound healing, complete transaction of tendon or deep vein thrombosis. At 12 months follow-up, 30 of 33 pts returned to their pre-procedure level of mobilisation with their usual walking aids or customised shoes. The inter-observer agreement was k = 0.86 for read 1 and k = 0.96 for read 2; and intra-observer agreement ranged from 0.93 to 1.00 for the double read indicating excellent inter-observer and intra-observer agreement.

CONCLUSION

TAL followed by weight-bearing TCC is a safe and well tolerated procedure when performed in an out-patient setting. The Charcot disease of the midfoot slowed in the early stages of midfoot CN and in some cases, receded. The new classification system is easy to use, reliable, reproducible and sensitive enough to detect changes in the disease progression.

Microscopic study of chronic charcot arthropathy foot bones contributes to understanding pathogenesis - A preliminary report

INTRODUCTION

Charcot arthropathy (CA) is non-infective, chronic destructive condition affecting the pes architecture of long standing diabetic patients with neuropathy. Even though several theories have emerged to disclose its pathogenesis, inflammatory cytokine induced osteoclastogenesis stands as the chief culprit. Studies on micro-architecture of foot bones of acute stage CA patients, describes mainly destructive phase of bone remodelling. Increased osteoclast cell activity is reported in all studies communicated. No study has to the best of our knowledge detailed the microscopic structure of chronic stage CA foot bones.

AIM

To study the microscopic structure of foot bones in patients with chronic CA.

MATERIALS AND METHODS

Foot bones were collected from the feet of chronic CA patients (six in number) who underwent corrective foot surgery in the Department of Podiatric Surgery of a tertiary care hospital. Control samples were collected from the feet of age matched non-diabetic controls (2 in number). The samples were fixed in formalin, decalcified in 10% nitric acid, processed, sectioned and stained with haematoxylin and eosin. Histopathology and histomorphometry analysis were performed by two different pathologists.

RESULTS

Trabeculae of chronic CA foot bones exhibited mainly a lamellar architecture, with reduced number of osteocytes and plenty of empty lacunae. Trabecular connectivity was lost and trabeculae showed considerable thinning. Trabecular osteoids lined by active osteoblast cells was a remarkable observation. Bone area was also considerably reduced in chronic CA foot bones.

CONCLUSION

Chronic stage CA foot bones presented features of both healing and fragile bone. The compromised bone quality may be due to thin and fragmented trabecular structure and reduced cellularity.

Effectiveness of Hindfoot Arthrodesis by Stable Internal Fixation in Various Eichenholtz Stages of Neuropathic Ankle Arthropathy

The optimal time to treat neuropathic (Charcot) arthropathy of the ankle and peritalar joint is controversial because of the various treatment options available and the variable results reported in published studies. We sought to determine the outcome of hind foot arthrodesis with stable internal fixation in patients with different Eichenholtz stages of arthropathy. We prospectively studied patients with substantial disabilities caused by neuropathic arthropathy in deformed, unstable ankle and peritalar joints, with or without ulcerations, who had undergone treatment from July 2007 to December 2012. All patients underwent ankle arthrodesis, autologous iliac crest bone grafting, and subtalar joint arthrodesis, with or without talonavicular joint arthrodesis, fixed internally with an intramedullary hindfoot nail, with or without an additional plate or cancellous screws. Of the 33 enrolled patients, 9 (27.3%) had stage I, 13 (39.4%) had stage II, and 11 (33.3%) had stage III Charcot arthropathy. The cause of arthropathy was diabetes mellitus in 25 (75.8%) patients. The duration of symptoms ranged from 1 to 120 (median 7) months. The mean follow-up period was 40 (range 12 to 76) months and did not differ markedly among the groups. The hindfoot scores, rate of salvage or amputation, or complication rates did not differ significantly across Eichenholtz stage. For the patients with stage I, II, and III, the preoperative hindfoot score was 50, 49, and 48, respectively (p = .9). The corresponding postoperative scores were 68, 68, and 70 (p = .5). We found no evidence that the effectiveness of hindfoot arthrodesis by stable fixation varied across the Eichenholtz stage of Charcot arthropathy involving ankle and peritalar joint. Furthermore, we found that stable internal fixation and bone grafting using a hindfoot nail results in an 84.84% union rate and salvages the unstable and disabled foot in 90.9% of patients with ankle and peritalar Charcot arthropathy.

Surgical Treatment Options for the Diabetic Charcot Hindfoot and Ankle Deformity

Charcot neuroarthropathy is associated with progressive, noninfectious, osteolysis-induced bone and joint destruction. When the ankle and/or hindfoot is affected by the destruction process, management is further complicated with collapse and destruction of the talar body, which increases instability around the ankle. In this patient population, arthrodesis is the most commonly used surgical procedure. Internal fixation, external fixation, or a combination of both can be used for the treatment. Decision making between them should be individualized according to the patient characteristics.

Outcome after protected full weightbearing treatment in an orthopedic device in diabetic neuropathic arthropathy (Charcot arthropathy): a comparison of unilaterally and bilaterally affected patients

Background

Charcot neuropathic arthropathy (CN) is a chronic, progressive, destructive, non-infectious process that most frequently affects the bone architecture of the foot in patients with sensory neuropathy. We evaluated the outcome of protected weightbearing treatment of CN in unilaterally and bilaterally affected patients and secondarily compared outcomes in protected versus unprotected weightbearing treatment.

Methods

Patient records and radiographs from 2002 to 2012 were retrospectively analyzed. Patients with Type 1 or Type 2 diabetes with peripheral neuropathy were included. Exclusion criteria included immunosuppressive or osteoactive medication and the presence of bone tumors. Ninety patients (101 ft), mean age 60.7 ± 10.6 years at first diagnosis of CN, were identified. Protected weightbearing treatment was achieved by total contact cast or custom-made orthosis. Ulcer, infection, CN recurrence, and amputation rates were recorded. Mean follow-up was 48 (range 1–208) months.

Results

Per the Eichenholtz classification, 9 ft were prodromal, 61 in stage 1 (development), 21 in stage 2 (coalescence) and 10 in stage 3 (reconstruction). Duration of protected weightbearing was 20 ± 21 weeks and 22 ± 29 weeks in patients with unilateral and bilateral CN, respectively. In bilaterally affected patients, new ulcers developed in 9/22 (41%) feet. In unilaterally affected patients, new ulcers developed in 5/66 (8%) protected weightbearing feet and 4/13 (31%) unprotected, full weightbearing feet (p = 0.036). The ulceration rate was significantly higher in bilaterally versus unilaterally affected patients with a protected weightbearing regimen (p = 0.004). Soft tissue infection occurred in 1/13 (8%) unprotected weightbearing feet and 1/66 (2%) protected weightbearing feet in unilaterally affected patients, and in 1/22 (4%) protected weightbearing feet of bilaterally affected patients. Recurrence and amputation rates were similar across treatment modalities.

Conclusions

Bilateral CN results in significantly more ulcers than unilateral CN and leads to slightly higher soft tissue infections. Protected weightbearing in an orthopedic device can reduce the risk for complications in acute CN of the foot and ankle.

Acute Charcot foot and diabetes: A primer for the vascular nurse

The clinical findings of the acute Charcot process includes a swollen, warm, and erythematous foot; although pain may be present, it is often mild and out of proportion to the clinical examination. The diagnosis is confirmed by radiologic imaging, and the diagnosis must be considered in any patient with diabetic neuropathy and unilateral foot swelling. Initial treatment calls for immediate immobilization of the foot. Failure to do so can lead to further foot damage, destruction, and possibly amputation. The patient with acute CN requires referral to a multidisciplinary team experienced in the care of the diabetic patient with this devastating condition. Patient education is a crucial component of the treatment plan when caring for a client with CN.

Treatment of the diabetic foot - to amputate or not?

Background

Diabetic foot infections are a frequent clinical problem. About 50% of patients with diabetic foot infections who have foot amputations die within five years. Properly managed most can be cured, but many patients needlessly undergo amputations because of improper diagnostic and therapeutic approaches.

Discussion

The article debates the pros and cons of amputation of the diabetic foot. The thesis is that if the guidelines on the management of the diabetic foot are followed primary amputation is only necessary for the unsalvageable diabetic foot. This approach would reduce the incidence of lower limb amputations in diabetic patients.

Summary

We favour the argument that a structured clinical and vascular assessment would help clinical decision- making as to which patients to hospitalize, which to send for imaging, or for whom to recommend surgical interventions. Endovascular procedures are the future in the treatment of diabetic arterial disease and hence the diabetic foot.